Basic Information
| Provider Information | |||||||||
| NPI: | 1134171366 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKE NORMAN UROLOGY PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 137 PROFESSIONAL PARK DRIVE | ||||||||
| Address2: | SUITE D | ||||||||
| City: | MOORESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281178522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046603322 | ||||||||
| FaxNumber: | 7046603330 | ||||||||
| Practice Location | |||||||||
| Address1: | 137 PROFESSIONAL PARK DRIVE | ||||||||
| Address2: | SUITE D | ||||||||
| City: | MOORESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281178522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046603322 | ||||||||
| FaxNumber: | 7046603330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HAGE | ||||||||
| AuthorizedOfficialFirstName: | G | ||||||||
| AuthorizedOfficialMiddleName: | ANNE | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE ADMIN | ||||||||
| AuthorizedOfficialTelephone: | 7046603322 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 790279R | 05 | NC | MEDICAID |